Central Venous Catheters and Munchausen Syndrome By Proxy
ABSTRACT & COMMENTARY
Synopsis: Central venous catheters are frequently placed in children later found to have Munchausen Syndrome by Proxy (MSBP) for problems such as malnutrition or failure to respond to usual therapies. Systematic evaluation for MSBP should be done before placing central venous lines in children with obscure conditions or conditions not usually requiring such intervention.
Source: Feldman KW, Hickman RO. The central venous catheter as a source of medical chaos in Munchausen Syndrome by Proxy. J Pediatr Surg 1998;33:623-627.
Feldman and hickman, pediatric surgeons at the children's Hospital of Seattle, studied the frequency of placements of central venous catheters (CVC) in children with Munchausen Syndrome by Proxy (MSBP). Data were collected by a retrospective chart review of 93 MSBP victims evaluated at their regional children's hospital from 1974 to 1996. Feldman and Hickman also reviewed records of children who had CVCs placed from 1991 to 1995 for uncommon reasons, such as failure-to-thrive or diseases that are usually treated with oral or subcutaneous medications (e.g., sinus infections or diabetes).
Of the 93 children with MSBP, 16 (17%) had at least one central line placed. As is usual, in all 16 cases, it was the mother who fabricated or induced the child's illness. The major reasons for the line placements were: severe nutritional depletion (8 cases) and administration of antibiotics (4 cases) or of antibiotics plus gamma globulin (3 cases). Line sepsis occurred in 56% of the patients, and two children died because of tampering with the central line (one from sepsis and one from air embolization).
Feldman and Hickman then reviewed 709 children who had CVCs placed during a five-year period. Line placements in children with cancer or chronic renal failure were excluded. Eight of these 709 patients (or 1.1%) had placements solely as a consequence of MSBP.
COMMENT BY JOHN M. LEVENTHAL, MD, FAAP
MSBP has become a fact of life in 20th century pediatrics. This unsettling article by pediatric surgeons in Seattle is another reminder of how difficult it may be to make the diagnosis of MSBP and how, sometimes, physicians in an effort to "do good" may actually become unintentional collaborators of an abusing mother and cause harm by unnecessarily placing central venous catheters. Certainly, it is easy to miss the clues of a fabricated or induced illness in a young child. It is important to think of the possibility of MSBP when you and your colleagues start saying, "We have never seen a case like this before," when test after test after test is being ordered to track down unusual symptoms or signs, or when extreme and invasive forms of therapy are being considered because "nothing else has worked." Be cautious in your diagnostic approach if the mother has some familiarity with the health field and is overly solicitous, understanding, and not only accepting but encouraging of further testing. This syndrome may be difficult to diagnose, but appropriate recognition can be life-saving. It is interesting that this report was written by pediatric surgeons whom in this article accept responsibility; but obviously, some, if not most, of the blame for these disasters must lie with the pediatricians who requested line placement in the first place.